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Abstract

Background

Previous research shows that how patients perceive encounters with healthcare staff
may affect their health and self-estimated ability to return to work. The aim of the
present study was to explore long-term sick-listed patients’ encounters with social
insurance office staff and the impact of these encounters on self-estimated ability
to return to work.

Methods

A random sample of long-term sick-listed patients (n = 10,042) received a questionnaire
containing questions about their experiences of positive and negative encounters and
item lists specifying such experiences. Respondents were also asked whether the encounters
made them feel respected or wronged and how they estimated the effect of these encounters
on their ability to return to work. Statistical analysis was conducted using 95% confidence
intervals (CI) for proportions, and attributable risk (AR) with 95% CI.

Conclusions

Long-term sick-listed patients find that their self-reported ability to return to
work is affected by positive and negative encounters with social insurance office
staff. This effect is further enhanced by feeling respected or wronged, respectively.

Keywords:

Background

Ways of promoting return to work among sickness absentees is an ongoing clinical as
well as political theme in many western countries, facilitating return to work among
long-term sickness absentees being a special topic of concern. Several different interventions
and programs have been introduced to this end, at different structural levels and
among different stakeholders, e.g. worksites, healthcare, and insurance offices [1-12].

The long-term sick-listed constitute a vulnerable group in different ways: apart from
their morbidity/health condition, they often have a lower educational level compared
to others, are more often immigrants, and have a lower disposable income compared
to their previous work income [13]. Moreover, to a large degree they are in the hands of both healthcare staff and social
insurance office staff, whose judgments and decisions have a major impact on their
access to rehabilitation measures, work adjustments, and their economic situation.
Long-term sickness absentees have themselves stated that their treatment by professionals
from healthcare and social insurance was as important as the different rehabilitation
measures [14,15]. For instance, respectful meetings have been reported to be of relevance for returning
to work [9].

In previously conducted studies regarding long-term sickness absentees’ encounters
with healthcare staff, based on data from the same questionnaire as the present study
uses, we found that both negative and positive encounters influence patients’ self-estimated
ability to return to work [16]. We also found that when patients feel respected in addition to experiencing their
encounters as positive, their self-estimated ability to return to work is significantly
facilitated, whereas patients feeling wronged in addition to experiencing their encounters
as negative, estimated that their ability to return to work was significantly impeded
[17]. Even though self-estimated ability to return to work is not the same as actually
returning to work, long-term sick-listed patients’ own beliefs on this matter is arguably
an important predictor for return to work, in a similar vein as self-estimated health
has been reported as the most valid predictor of a long life [9,18].

Since it is social insurance office staffs who decide whether patients fulfil the
criteria for sickness benefits, it is also of interest to investigate patients’ perceptions
of encounters with these actors. The aim of the present study was to explore long-term
sick-listed patients’ encounters with social insurance office staff and the impact
of these encounters on their self-estimated ability to return to work. To further
illuminate these patients’ experiences of encounters with social insurance office
staff, those experiences were compared with their experiences of encounters with healthcare
staff.

Methods

In this cross-sectional study we analysed data from answers to a population-based
questionnaire sent out to a random selection of half of all people in Sweden who in
March 2004 had an on-going sick-leave spell that had lasted for at least four and
at the most eight months (n = 10,042). This duration of the sick-leave spell was chosen
so that the absentees would have had a chance to have personal contact with the social
insurance office but still have a good chance to return to work. A comprehensive questionnaire
was developed, based on several qualitative and quantitative studies of how sickness
absentees experience encounters with social insurance and health care staff [14,19-21].

We studied their experiences of positive and negative encounters with social insurance
office staff. All participants received the same questionnaire. Those who had experienced
positive encounters only were subsequently asked to specify the experience by choosing
from a list of different positive encounters, such as ‘Listened to me’ and ‘Believed
me’. They were also asked what kind of feeling the encounters had resulted in, including
feeling respected. Those with experiences of negative encounters only or a mix of
positive and negative encounters were similarly presented to a list of negative encounters,
such as ‘Did not listen’ and ‘Was too impersonal’, and they were also asked what kind
of emotions the encounters resulted in, including feeling wronged. Finally all participants
were asked whether or not the encounters had influenced their ability to return to
work, response alternatives being ‘facilitating’, ‘not influencing’, or ‘impeding’.
The lists of encounter items were developed partly based on the outcome of focus-group
interviews [19].

In addition, the respondents were asked if they were sick-listed due to (a) mental
disorders, (b) musculoskeletal pain, or (c) other somatic diseases.

Focusing on the associations between feeling respected / wronged in encounters with
social insurance office staff and self-estimated ability to return to work, we performed
logistic regression analysis adjusting for different background variables such as
sex, age, educational level, and diagnosis. Adjustments made no substantial difference
to the results. Therefore, we present the results as proportions with a 95% confidence
interval (CI) for those who estimated that return to work was facilitated when experiencing
positive / respectful encounters compared to those who stated that it was not influenced
or impeded. The same was done for the proportion of those whose self-estimated ability
to return to work was impeded when exposed to negative/wrongful encounters compared
to those who stated that it was not influenced or facilitated.

The associations between positive encounters and feeling respected, and negative encounters
and feeling wronged, are presented as attributable risk (AR) with a 95% CI, using
the R-package pARtial [22]. All ARs were adjusted for sex, age (20–29, 30–39, 40–49, 50–59, and 60–65 years),
education (compulsory school, 2 years in high school, 3–4 years in high school, university
credits, completed university degree), and reason for being sick-listed (Table 1). AR takes into account both frequency and strength of association in a certain population.
AR for those who felt wronged in relation to specific encounter-items could be interpreted
as: If social insurance staffs had, for example, listened to the patients, 39.8% would
not have felt wronged, (Table 2). Results concerning return to work were presented as proportions with 95% CI. When
comparing the results regarding social insurance office staff with results regarding
healthcare staff, we included results that have been published elsewhere [17,23].

Table 1.Demographic presentation of the study population, responders, and of the sample population
that had experienced negative encounters with social insurance staff

Table 2.Positive encounters in terms of feeling respected among long-term sick-listed patients
and their contact with social insurance office staff

The study was approved by the Regional Research Ethics Committee in Linköping, Dnr
03–261.

Results

The response rate was 58% (n = 5,802) of the original sample (Table 1). When asked about experiences of negative and positive encounters, there was an
internal drop-out of 231 ending up with 5,571 participants. Of these, 78.4% had experienced
positive encounters and 21.6% had experienced negative encounters. When the respondents
were asked about feeling respected or wronged, there was an additional internal drop-out,
leaving 4,535 participants, of whom 76.5% had felt respected and 23.5% had felt wronged
(Figure 1).

Figure 1.Distribution of the long-term sickness absent population who had experienced negative
or positive encounters with social insurance staff. The respondents are divided into those who felt wronged and those who did not feel
wronged, or felt respected or did not feel respected.

Of those participants who had experienced positive encounters, 87.8% (n = 3,047) reported
that they had also felt respected. Of those who had experienced negative encounters,
55.1% (n = 586) reported that they had also felt wronged (Figure 1).

Effects of positive encounters and feeling respected

We found a high attributable risk (AR) for having experienced positive encounters
and the patient’s feeling respected. Being listened to and being believed were among
the types of behaviour with the highest AR (Table 2).

Of those with experience of positive encounters, 26.9% (95% CI: 22.1-31.7) stated
that it facilitated their self-estimated ability to return to work. This ability was
significantly increased if they also felt respected [49.3% (47.5-51.1)]. In particular,
patients with psychiatric disorders estimated that their ability to return to work
was significantly improved when they felt respected (Table 3).

Table 3.Proportions of those who, following contact with social insurance office staff, reported
that encounters facilitated return to work (with a 95 per cent confidence interval)

Impact of negative encounters and feeling wronged

The risk of feeling wronged if exposed to negative encounters was found to be high.
The highest AR was linked with being treated with nonchalance, being disbelieved,
and having one’s condition doubted (Table 4).

Table 4.Negative encounters in terms of feeling wronged among long-term sick-listed patients
and their contact with social insurance office staff

Of those with experience of negative encounters, 29.1% (24.6-33.6) stated that these
experiences impeded their ability to return to work. A significantly greater proportion
of the respondents who in addition felt wronged described themselves as impeded from
returning to work [51.3% (47.1-55.5)]. Compared to patients suffering from somatic
disorders, more patients with mental disorders reported this effect when also feeling
wronged (Table 5).

Table 5.Proportions of those who, following contact with staff of the social insurance office,
reported that they were impeded from returning to work (with a 95% confidence interval)

We found no significant differences based on sex or social status concerning the different
aspects discussed above.

Discussion

We found high ARs for positive encounters with social insurance office staff and feeling
respected and for negative encounters and feeling wronged. We also found that feeling
respected had a facilitating effect on a self-reported return-to-work ability. Similarly,
we found that feeling wronged had an impeding effect on self-reportedly ability to
return to work. The positive effect of feeling respected on self-estimated ability
to return to work was particularly manifested among patients with mental disorders.
Our results are in line with previous findings that long-term sick-listed patients
are sensitive to whether their encounters are respectful or not [9].

Specific items of positive encounters particularly associated with feeling respected
were being listened to, being believed in, and having one’s questions answered. Specific
items of negative encounters associated with feeling wronged were not being believed,
having one’s condition doubted, and having one’s motivation for work questioned. “Nonchalant
behaviour” was the item of negative encounters with the highest AR, but it is highly
unspecific and might cover several of the more specific items. The same goes for the
item of positive encounters with the highest AR, “Treated me with respect”.

From other studies it has been reported that female sick-listed patients have special
preferences when it comes to rehabilitation and return to work [9]. On this backdrop it is interesting that we did not find any gender differences.
This difference might be due to different methods; it might be easier to recognize
gender aspects in qualitative research compared to quantitative studies.

Comparing encounters with social insurance office staff and healthcare staff

Our survey regarding encounters with social insurance office staff also collected
data regarding patients’ encounters with healthcare staff, published elsewhere [17,23,24]. Regarding positive encounters and feeling respected, a majority of encounter items
yielded significantly higher ARs among social insurance staff compared to healthcare
staff. Also, negative encounters and feeling wronged displayed a tendency for social
insurance staff to score higher ARs [17,23]. The few items which had significantly higher ARs are rather interesting. The long-term
sick-listed seem to feel that it is worse if the staff at a social insurance office
question their motivation to work, reject their suggested solutions, or threaten them.
How can these differences be explained? Compared to healthcare staff, who are primarily
concerned with patients’ health, social insurance office staff have other tasks associated
with societal, economic, and regulatory interests. It is part of their job to assess
their clients’ right to sickness benefit. Being questioned on this matter implies
a threat to the income of the concerned individuals and can therefore become a very
sensitive matter in that context. This might explain the attitude towards having one’s
willingness to work questioned or one’s suggestions for handling the situation rejected.
Perhaps the threats experienced concern financial actions that social insurance office
staff might take if the client does not behave in accordance with requirements.

When comparing positive encounters associated with long-term sick-listed individuals’
feeling of being respected by social insurance office staff or healthcare staff, we
identified several significant differences. The respondents stated that it is more
important that social insurance office staff believe in them and in their ability
to work, let them take responsibility, and make reasonable demands, compared to healthcare
staff doing so. Again, these differences might be explained by the different roles
of social insurance office staff and healthcare staff.

Need to increase awareness of negative encounters

Patients might react differently to the same kinds of encounters, depending on their
personal sensitivity and circumstances [12]. Sometimes healthcare staff and social insurance office staff might be provoked or
intimidated by patients/clients and confrontations might occur [25]. Studies have indicated that it is unreasonable to assume that healthcare staff intentionally
wrong patients [26]. Similar reasoning might be plausible when discussing social insurance office staff.
Yet both professional groups need to become aware of what kinds of encounters are
negatively experienced by patients and might cause them to feel wronged. Even if patients’
perceptions do not always correspond to objective negative or wrongful behaviour,
these perceptions need to be taken seriously, because they seem to have consequences,
for example effects on patients’ self-estimated ability to return to work. Apparently
the quality of encounters is not solely a matter of etiquette.

Different perceived effects on return to work

There were also differences in the encounters’ perceived effect on return to work.
However, when comparing the two contexts, we found no significant difference regarding
feeling wronged and self-estimated effect on return to work. Nevertheless, for positive
encounters in which patients also felt respected, the behaviour of healthcare staff
was more commonly perceived than that of social insurance office staff as facilitating
return to work. Yet the impact in the latter case is not negligible, according to
the respondents’ self-estimations.

Even without considering the consequences for return to work, it seems reasonable
to promote encounters that facilitate individuals’ feeling of being respected and
avoid encounters that make them feel wronged. When this aspect is also considered,
the reasons become even stronger. From the perspective of positive encounters and
feeling respected, social insurance staff ought particularly to avoid questioning
patients’ work morality, rejecting their suggested solutions, making unreasonable
demands, and threatening the patient.

Limitations

The present study was a cross-sectional study, with its inherent limitations. Although
the response rate was relatively high, there was also an internal drop-out that should
be taken into consideration. The internal dropout rate increased in every combined
step (Figure 1).

The focus was on long-term sick-listed patients’ encounters with social insurance
office staff and the self-estimated effects of these encounters on return to work.
Although self-estimated work-capacity might influence actual capacity, self-estimated
effects and actual effects on return to work are distinct entities. The results should
therefore be interpreted carefully about the effects of positive and negative encounters
on actual return to work. Furthermore, we cannot generalize from these results to
individuals who have no experience of long-term sick leave. Yet, our results suggest
a focus for future research.

The fact that respectful encounters were most frequent and strongest associated with
feeling respected is no surprise – the whole purpose of including this item was to
validate the questionnaire. Accordingly, we have not considered it in the discussion.
Disrespectful encounters were used in a corresponding vein in relation to feeling
wronged.

Conclusions

A majority of patients with positive experiences from encounters with social insurance
office staff also felt respected and estimated that their return to work was facilitated
by these types of encounters. Feeling respected was especially associated with being
listened to and being believed in. The positive effect of feeling respected was particularly
manifested among patients with mental disorders. Correspondingly, a majority of those
who, in addition to having experienced negative encounters, also felt wronged stated
that their return to work was impeded. Feeling wronged was especially associated with
being disbelieved, getting one’s condition doubted, and having one’s motivation to
work questioned.

Even though encounters with social insurance office staff seem to have less effect
on patients’ self-estimated ability to return to work than corresponding encounters
in healthcare, the impact is not negligible. The results indicate that there is room
for improving patients’ encounters on the part of social insurance office staff, in
particular by listening to and believing the patients, refraining from expressing
doubt regarding their conditions, and not questioning their motivation to return to
work.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

NL took a leading part in the conception and design of the study and in the interpretation
of the results, wrote the first draft of the manuscript, and later contributed with
substantial revisions. MW contributed to the conception and design of the study, contributed
substantially to the statistical analysis and the interpretation of the results, and
revised the manuscript for important intellectual content. DO contributed substantially
to the statistical analysis and the interpretation of the results, and revised the
manuscript for important intellectual content. KA designed the study questionnaire,
provided data, contributed substantially to the interpretation of the results, and
revised the manuscript for important intellectual content. GH contributed to the conception
and design of the study, contributed substantially to the interpretation of the results
and the consistency of the paper, and took a leading role in finalizing the manuscript.
All authors read and approved the final manuscript.